Life Membership Application Form
Instructions
Please print or type. Please submit this form to your state/territory president for verification. To qualify for life membership, you must
have been an active or affiliate member of NEAFCS for at least 5 years and have retired, resigned or otherwise have become ineligible
for active or affiliate membership. Should you ever re-enter the extension service, you will be required to resume active membership
status and pay annual dues. However, you will not be re-assessed the life membership fee should you again leave the extension
service. The one-time fee for Life Membership is $300 (three times 2013 Active member dues).
First Name
Middle Name
Last Name
Other name(s) under which your membership may have been listed:
Home Address
City
Home Phone
Home Email Address
Date of Retirement/Resignation
State/Territory from which you retired/resigned
State/Territory
Zip
Dates of employment by that state/territory (From/To)
I was a member of NEAFCS as follows:
Dates: From
To
State/Territory
County
Dates: From
To
State/Territory
County
Dates: From
To
State/Territory
County
Dates: From
To
State/Territory
County
Dates: From
To
State/Territory
County
Certification
I certify that I was an active or affiliate member of NEAFCS for at least 5 years, and that I have retired, resigned or otherwise become
ineligible for active or affiliate membership. I understand that, should I re-enter the extension service, I will be required to resume
active or affiliate membership and pay annual dues. Should I leave extension again, my membership will revert to life membership.
Applicant’s Signature
Date
Verification
I verify that the above information is correct.
State/Territory President’s Signature
Date
Submit this form directly to your State Affiliate President